Healthcare Provider Details

I. General information

NPI: 1083077903
Provider Name (Legal Business Name): POOJA SHAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE
OLYMPIA FIELDS IL
60461-1010
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 219-866-5141
  • Fax: 708-679-2161
Mailing address:
  • Phone: 215-590-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4878
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD468674
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA11569300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMT217563
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036172040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: